The pope was right about condoms, says Harvard HIV expert
Dr Edward Green, director of Harvard's HIV Prevention Research Project, who came to the defence of Pope Benedict during last week's international row over condoms in Africa, says his research program at Harvard University has come to an end.
In an extended interview on today's Sunday Sequence, Dr Green told me why he decided to voice his support to Pope Benedict's controversial claim that condom distribution is exacerbating the problem of Aids in Africa. He also challenges the scientific authority of the United Nations Aids organisation, and argues that condoms should be used in Africa as part of a combination strategy to combat Aids. Dr Green says, "I have always been politically incorrect. I have always questioned authority and tried to speak truth to power whatever the consequences." A full transcript of the interview is below the line.
Edward Green: What the Pope said was the distribution and marketing of condoms would not solve the problem of African Aids and that it might even exacerbate the problem. And I think it was that second comment that really set the critics off, really upset a lot of people. I can understand that, because I have worked in Aids prevention for a long time. In fact, I worked as a condom and contraceptive social marketer at the beginning of the pandemic--I was working in family planning. I am part of a group of researchers that have been looking for the behavioural antecedents to HIV prevalence decline in Africa. We now see HIV going down in about 8 or 9 countries in Africa and in every case we see a decrease in the proportion of men and women who report having more than one sex partner in the past year. So when the Pope said that the answer really lies in monogamy and martial faithfulness, that's exactly what we found empirically.
William Crawley: What's the evidence that you are appealing to that condom distribution has made things worse in Africa?
Edward Green: Because we have for a number of years now found the wrong kind of association between condom-availability and levels of condom use.. You see the wrong kind of relationship with HIV prevalence. Instead of seeing this associated with lower HIV infection rates, it's actually associated with higher HIV infection rates. Part of that is because the people using condoms are the people who are having risky sex. It's just like there is more bed nets in use in countries with malaria than in countries without such high levels of malaria.
William Crawley: So it would be a mistake to draw any causal connection between an increase in the use of condoms and an increase in HIV prevalence. That would be a mistake, wouldn't it?
Edward Green: We don't have any proof. The closest thing we have are some prospective studies that follow the same populations. There was one where--Norman Hurst of the University of California was one of the authors, it was published in the journal Aids--where they followed two groups of young people in Uganda, and the group that had the intensive condom promotion--and they were provided condoms after three years--they actually were found to have a greater number of sex partners. So that cancels out the risk reduction that the technology of condoms ought to provide. That's the phenomenon known as risk compensation.
William Crawley: What do you mean by risk compensation?
Edward Green: This is when somebody uses a technology, such as condoms or sun-block, to reduce the risk, but then they compensate for that, or actually lose the risk reduction, by exposure to the sun longer in the case of sun-block or they take greater sexual risks in the case of condoms.
William Crawley: What you have suggested is that the use of condoms in Africa is a complicated story: it relates to abstinence and monogamy programmes as well. In those countries where there has been a reduction in HIV infection, such as Uganda, all three seem to play a part--abstinence, monogamy and the use of condoms. At least according to the United Nations Aids organisation (UNAids), all three play a part. Do you have any evidence at all that condoms are making the problem worse, which is what the Pope suggests?
Edward Green: Well I just mentioned a study that was done in Uganda that suggests that with intensive promotion of condoms you actually have people increasing the number of sexual partners, so in that sense--
William Crawley: But you have already accepted that there can be no causal inference drawn from that study.
Edward Green: Well, except that the phenomenon of risk compensation, or behavioural dis-inhibition, is real, and there have been articles, including published in The Lancet, about this phenomenon. So there could be a causal connection.
William Crawley: The Lancet has described the Pope's comments, which you agree with, as a distortion of scientific evidence.
Edward Green: That's because The Lancet is not thinking about the generalised epidemics of Africa. I hasten to add--and I have tried to do this in all of my interviews, although sometimes only part of my interviews are quoted--I point out that at national levels, we see condoms working in epidemics like those of Thailand and Cambodia. But in the generalised epidemics of Africa--well, there was a UN Aids study done in 2003 by Hearst and Chen, it was actually published in the peer-reviewed journal Studies in Family Planning in 2004, and they conclude that there is not a single country in Africa where HIV prevalence has come down primarily because of condoms.
William Crawley: You accept that condoms do work in other parts of the world, like the Western World, for example?
Edward Green: I do. And they should have a back-up role even in the generalised epidemics of Africa. I believe condoms should be made available to everyone. It should be, and as you say, the ABC strategy: Abstain, Be faithful, use a Condom. Condoms may well have contributed to the prevalence decline in Uganda.
William Crawley: That's a serious ideological difference between yourself and the Pope. He doesn't think that condoms should be used, even in the case of married Catholic couples where one of the partners is HIV-positive.
Edward Green: Yes, well, I don't agree with that. And, I have said that I am not a Catholic, and I am not talking about condoms in any sort of moral-ethical sense. I am talking about what has been found to work and not work. So, yes, the article I mentioned by Hearst and Chen is very clear that condoms work in certain types of situations and certain sub-populations and condoms have had a positive national impact in certain concentrated epidemics. So, yes, I don't agree with the Pope across the board.
William Crawley: Which brings us back to Africa. And to try to explain why there has been a mixed experience in terms of condom distribution in Africa, you are appealing to this possible mechanism of risk compensation. Which is another way of saying, really, that when people feel they are protected by a condom they engage is other risky behaviours. And one could say in response to that, this is not a criticism of condom distribution, it's a criticism of the education programmes that accompany condom distribution, surely?
Edward Green: Yes, we can say that. It's just I am somebody, who, as I mentioned I think, worked in family planning at the beginning--before the Aids pandemic began. And I think we have tried just about everything that can be tried as far as getting people to use condoms consistently and correctly in general populations. You know it's possible in certain sub-populations, such as commercial sex workers and their clients--even in Cambodia and Thailand, it was commercial sex workers in brothels where the 100 per cent condom policy was implemented and was so successful. But once you get outside of brothels are some situations where you have some control, it's again very difficult to get people to use condoms. So, yes, it's the fault of the person and not with the physical device the condom.
William Crawley: You can see why some people perhaps misunderstand your position, Dr Green, because you make a blunt statement like "the Pope is right about this" and "he is right on the science". And it is a much more complicated story once we explore it a little bit. You are encouraging the use of condoms in Africa. You are just saying: in addition to that, we should take seriously abstinence and, particularly, "be faithful" (monogamy) programmes, as well in Africa. That's a very different position to the one that the Pope holds to.
Edward Green: Well, you could phrase it that way. Or you could say: the Pope said that the distribution and marketing of condoms is not the solution or the best solution to African Aids; rather, it is monogamy and faithfulness. And the evidence is so clear about partner reduction. If you promote monogamy and faithfulness what you get is a reduction in the number of partners and concurrent partners. We haven't mentioned concurrency: we are finding that if you have partners, ongoing relationships that overlap, these are particularly effective in transmitting HIV. The evidence is so clear about that, that one of the reasons I stuck my neck out, knowing that I would get into a lot of trouble with my peers and colleagues, is because the Pope didn't repeat the usual condoms-versus-abstinence but instead mentioned fidelity and monogamy.
William Crawley: The United Nations Aids organisation says recent analysis of the Aids epidemic in Uganda confirms, and I am quoting, "that increased condom use in conjunction with delay in age and first sexual intercourse and reduction of sexual partners was an important factor in the decline of HIV prevalence in the 1990s". They say it was all three: ABC. The Pope says it was AB. And you seem to be agreeing with him.
Edward Green: Well, you must understand that UN Aids is not a scientific body. It's an advocacy body. And, in fact, a former director, Peter Piot, in recent years has been saying that what they do is "evidence-informed" rather that "evidence-based". If you stop and think about that distinction, you know, it suggests that UNAids draws upon the evidence that supports what it believes.
William Crawley: We shouldn't trust the UNAids organisation on this?
Edward Green: I would be very careful about trusting the UNAids organisation for anything scientific, anything having to do with, for example, statistics about Aids. They have had to back-pedal and retract a lot of their basic statistics. It may seem pretty shocking for somebody like me to disagree with UNAids, but the fact is that UNAids is changing its thinking on this matter. As a matter of fact, in a very few days, there is going to be joint statement released by our Harvard programme, the Southern Regional Office of UNAids, and the Southern Regional Office of the World Bank, saying that the primary intervention for Aids in Southern Africa should be to discourage multiple and concurrent partners and that condom promotion is a secondary backup strategy.
William Crawley: How can you believe that condom promotion should be a back up strategy and also believe that "condom distribution is making matters worse in Africa"?
Edward Green: Well, I wouldn't keep saying that way, I am--
William Crawley: That's what the pope said, and that's what you say you agree with--
Edward Green: Higher condom use and higher infection rates could be explained in a number of ways: we should be alert to the fact that one of those ways could be dis-inhibition. This has been sort of a taboo word in the field of Aids. We don't want to think that, possibly, we are making the situation worse by giving people a greater sense of security than they ought to have. But, you know, we should think about that possibility.
William Crawley: But condoms are either making the problem worse in Africa, or they are a backup strategy, which is it?
Edward Green: Well, I would say that they should, again, be made available. They should be available as a backup strategy. It's obviously better to not indulge in a risk behaviour ... Lets go back to what we know about condoms: when they are used consistently, when they are used consistently, they provide, under more or less ideal conditions, about 80 to 85 per cent risk reduction, compared to those who don't use them at all. But how many--what percentage of any large national population--uses condoms consistently? Probably nowhere in excess of 5 per cent.
William Crawley: There does seem to be a world of a difference, Dr Green, between what you have just said, and the Pope's simple claim that condoms are aggravating the problem in Africa. Those two positions do not seem to be the same, and yet you say you agree with the Pope.
Edward Green: I told you that I stuck my neck out knowing it would be controversial, because the Pope said that the distribution of condoms was not the solution, that monogamy and fidelity was. It depends on how you look at condoms. Condoms, as a technology, can work in certain circumstances. Yes, they should be a backup if people are not going to avoid the risk altogether. But looking at it from a public health standpoint, we have not seen that condoms have worked at the population or national levels in Africa. So you can interpret that I suppose in different ways.
William Crawley: Let's come to the situation that your programme faces at Harvard University. You have said that you have managed to put yourself in some difficulties with some of your peers. What is the situation you are facing now at Harvard?
Edward Green: Well, before this most recent situation came up with my name being in the news a lot in connection with the Pope, our project was coming to an end, and actually has come to an end. We are running currently on a no-cost extension for another approximately 11 months.
William Crawley: So you regard your position on this as somehow "politically incorrect" over the years in terms of the politics of all of this?
Edward Green: Yes, my position is very politically incorrect. I have always been politically incorrect. I have always questioned authority and tried to speak truth to power whatever the consequences.
William Crawley: Are you are paying an institutional price for that in terms of Harvard?
Edward Green: Well, I don't know. I don't know whether our programme would have ended when it's ending if I had been more politically correct. You would have to ask Harvard.